Adolescent with Diabetic Ketoacidosis, Hypothermia and Pneumomediastinum

Audience The target audience of this simulation is emergency medicine residents and medical students. The simulation is based on a real case of a 12-year-old male who presented obtunded with shortness of breath and hypothermia who was ultimately diagnosed with diabetic ketoacidosis (DKA) and pneumomediastinum. This case highlights the diagnosis and management of an adolescent with new onset diabetic ketoacidosis and pneumomediastinum with deterioration of status, as well as important ventilator settings if intubation is required in the setting of diabetic ketoacidosis. Background Type 1 diabetes is a common disease in the pediatric population with the prevalence being approximately 2.15 per 1000 youths and diabetic ketoacidosis being the presenting status in 30–40% of the patients.1 Physicians who evaluate a child with altered mental status must have diabetic ketoacidosis in their differential. In the setting of mechanical ventilation in patients with diabetic ketoacidosis (DKA), special care must be taken. Mechanical ventilation in these patients comes with increased risk, morbidity, and mortality. Risk factors for pneumomediastinum include lung disease such as asthma, chronic obstructive pulmonary disease (COPD), and malignancy, but also can occur in the acute setting of vomiting or trauma.2 Educational Objectives By the end of the simulation, learners will be able to: 1) develop a differential diagnosis for an adolescent who presents obtunded with shortness of breath; 2) discuss the management of diabetic ketoacidosis; 3) discuss management of hypothermia in a pediatric patient; 4) discuss appropriate ventilator settings in a patient with diabetic ketoacidosis; and 5) demonstrate interpersonal communication with family, nursing, and consultants during high stress situations. Educational Methods This is a high-fidelity simulation that allows learners to manage the diagnosis and treatment of diabetic ketoacidosis and hypothermia in an adolescent patient. Participants participated in a debriefing after the simulation. There should be approximately 4–5 learners per case. This simulation was performed in 3 sessions. Each learner performed this simulation one time. Research Methods The effectiveness of this case was evaluated by surveys given to learners after debriefing. Learners gave quantitative and qualitative results of their feedback using a 1–5 rating scale and open-ended written questions. This case was trialed with residents in their first through third years of training as well as fourth year medical students. Results Feedback was very positive, with 19 residents completing the post-simulation survey. They enjoyed the case and reported they would feel more comfortable in a comparable situation in the future. Four survey questions were asked of the participants. On average, learners stated they felt the simulation improved their ability to manage a pediatric DKA patient, and their knowledge of complications and appropriate ventilator settings improved (modes of 5, 4 and 5, respectively). Discussion Diabetic ketoacidosis is a common and critical diagnosis for emergency medicine physicians to consider in the setting of altered mental status in a pediatric patient. This simulation has multiple steps and is based on a real case of an obtunded and hypothermic pediatric patient who was ultimately diagnosed with diabetic ketoacidosis complicated by pneumomediastinum. Topics Diabetic ketoacidosis, pneumomediastinum, hypothermia, altered mental status, pediatrics, adolescent, intubation, hypoxia, ventilator settings, cardiac arrest, emergency medicine, medical simulation.


Linked objectives and methods:
An obtunded adolescent patient presenting to the emergency department must be evaluated and treated quickly.The patient in this case is obtunded and hypothermic on arrival and quickly becomes unresponsive and hypoxic.Learners will be presented with a case of a critically ill pediatric patient who will require timely diagnosis and resuscitation.They will need to formulate an appropriate differential diagnosis (objective 1).The laboratory testing will reveal a blood sugar that reads "high" with associated acidosis, and chest x-ray will show pneumomediastinum.The learners will then initiate treatment of diabetic ketoacidosis (objective 2).Learners will have to administer IV fluids and insulin to treat the patient.Despite this, the patient will become hypoxic secondary to the patient's pneumomediastinum requiring intubation, and the learners will be required to initiate appropriate ventilator settings for a patient with diabetic ketoacidosis.Given this patient is Kussmaul breathing at a rate of 30 breaths per minute, this rate must be matched in order to ensure the patient does not have worsening acidemia.Tidal volume may be calculated via approximately 6ml/kg of Ideal body weight (objective 3).Should inappropriate ventilator settings be requested, the patient will deteriorate to cardiac arrest requiring appropriate Advanced Cardiovascular Life Support (ACLS) for resuscitation.During the simulation, a family member will be present who will require frequent updates, and the learners should be able to communicate with them as well as nursing staff and the pediatric intensivist over the phone (Objective 4).At the end of the simulation, the learners will debrief and discuss appropriate management for patients they may encounter with similar presentations.

Objectives:
By the end of this simulation, the learner will be able to: 1. Develop a differential diagnosis for an adolescent who presents obtunded with shortness of breath 2. Discuss the management of diabetic ketoacidosis 3. Discuss the management of hypothermia There was also a family member who was portrayed by one of our education attending physicians who provided history.In this simulation, one tip would be to have clear instructions for the simulation technician for when to have the patient lose pulses.We were not clear enough with our technician, and when inappropriate ventilator settings were placed, the patient maintained pulses.The effectiveness of this simulation was measured using a survey rating the learners' understanding of management of pediatric diabetic ketoacidosis.A scale of 1-5 where 1 (completely disagree) to 5 (completely agree) was used to answer four questions: In total, 19 residents and medical students completed the survey.All surveys were anonymous.The mode response for question 1 was 4, suggesting that participants had a good level of background knowledge of this disease process.For questions 2-4, which assessed how these participants felt about their knowledge after the case, the mode responses were 5, 4, and 5 respectively.They generally felt that this simulation enhanced their learning and understanding of how to treat a critical patient with diabetic ketoacidosis.Basic metabolic panel #5 Complete blood count #6 Venous blood gas #7 Beta-hydroxybutyrate Background and brief information: An obtunded 12-year-old male presents to the emergency department (ED) via private vehicle.Grandmother provides history that the patient had been feeling anxious earlier in the day with numerous bouts of vomiting.The patient has no previous medical problems and is on no medications.

Initial presentation: Presents obtunded via private vehicle
How the scene unfolds: There are 3 stages to this simulation: Stage 1) Patient will be mildly hypoxic, hypothermic, and tachycardic and will require supplemental oxygen and intravenous (IV) fluid resuscitation with consideration for warming.He will be found to be in DKA and will receive appropriate treatment with IV fluids and insulin.
Stage 2) Patient will continue to become more hypoxic requiring intubation.Learners will need to get a chest x-ray to articulate appropriate ventilator settings.
Stage 3) If appropriate ventilator settings are chosen (specifically respiratory rate), the patient will stabilize.If inappropriate ventilator settings are chosen, the patient will deteriorate to asystole requiring one round of ACLS and correction of vent settings.In our simulation, two of our groups did not put in appropriate ventilator settings and the patient went into asystole.One group quickly recognized their error.The third group required prompting from the nurse who asked, "What are the patient's ventilator settings?"The patient will then be dispositioned to the Pediatric Intensive Care Unit (PICU) after discussion with the admitting team.The family will be updated throughout the case.In our simulation, senior learners were paired with junior learners.However, in the setting of a case where there are only junior learners, ventilator settings may be provided, and cardiac arrest omitted.

History:
• History of present illness: The patient was feeling unwell for three days with nausea, vomiting, and fatigue.He seemed anxious and short of breath this morning; his stepmother thought this may be a panic attack and gave 0.5 mg orally of lorazepam.
The patient has no history of anxiety, and the medication belonged to the stepmother.Insulin should be started at between .05-.1unit/kg/hr.Potassium levels, glucose levels, and anion gap will be drawn frequently to monitor progress.Sodium bicarbonate should be avoided unless there are signs of severe respiratory or circulatory failure.

Pearls: Hypothermia
• Must evaluate degree of hypothermia based on severity and core body temperature.If body temperature is greater than 32° C, then management can focus on removal of wet clothes and placing in a warm environment with warm blankets.For body temperatures below that but in patients who are still hemodynamically stable, options include a forced air warming blanket.If there is any sign of hemodynamic instability in patients with hypothermia, treatment should move towards warm IV fluids, intrapleural, or intraperitoneal warm fluid wash.ECMO may be indicated in extreme cases.The recommended rate of rewarming is .5-2°C per hour. 5

Pearls: Ventilator Management
• While patients in DKA can present very obtunded, intubation should only be considered if truly necessary because a patient is able to improve his or her acidemia with an increased respiratory rate that is difficult to match using a ventilator.Patients with DKA have Kussmaul breathing due to respiratory compensation from severe metabolic acidosis.Normal ventilator settings will worsen acidemia and increase mortality. 2owever, given a DKA patient's higher risk for acute respiratory distress syndrome (ARDS), peri-intubation lung protective tidal volumes should be maintained. 6This means primary focus should be on maintaining a tidal volume similar to the patient's volumes prior to intubation.Diabetic ketoacidosis is associated with decreased total body stores of magnesium and potassium which in turn causes patients to have concerning muscle weakness which can prolong patient's ventilator time. 8

Pearls: Pneumomediastinum
• Pneumomediastinum is a rare condition of free air in the mediastinum.Generally seen in young, thin males, it is commonly preceded by a history of nausea with vomiting, smoking, trauma, or recent medical instrument use.Treatment is generally supportive by providing antiemetics, analgesia, bedrest, and supplemental oxygen as needed.For patients with extensive subcutaneous emphysema or hemodynamic instability, thoracic surgery can be involved, and these patients can sometimes be treated in the operating room.Prophylactic antibiotics are generally not indicated. 7

Pearls: Cerebral Edema
• Cerebral edema must be on the differential diagnosis for patients with DKA and altered mental status.Signs of cerebral edema include worsening vomiting, mental status change, hypertension, bradycardia, or worsening headache.This has found to be associated with bicarbonate use and is sometimes thought to be associated with more aggressive IV fluid rates; however, this is controversial.Should the provider have concerns for cerebral edema, head of bed should be elevated and urgent consult to PICU should be placed.
Diabetic Ketoacidosis (DKA) is a life-threatening illness that must be identified quickly.It is often the first presentation of Type 1 diabetes in the pediatric population.Common symptoms include nausea, vomiting, fatigue, abdominal pain, altered mental status.DKA leads to profound acidemia, and without treatment can deteriorate to cardiovascular collapse.• Etiology: Incidence of Type 1 diabetes is 22.3 per 100,000 patients per year with 1/3 of those patients presenting in the setting of diabetic ketoacidosis. 3Risk factors for diabetic ketoacidosis include low socioeconomic status, non-white patients, and poor access to healthcare.Inciting factors for DKA include illness, new medication, or recreational drug/alcohol use.• Diagnostic testing: Initial finger stick blood glucose of >250 mg/dL should warrant investigation for DKA.Basal metabolic panel (BMP) should be ordered to evaluate potassium and anion gap; arterial or venous blood gas will assess level of acidemia in the patient, and a beta-hydroxybutyrate (or other measure of acetone) can be considered as adjunctive testing.Imaging and lab testing to evaluate for inciting causes of DKA should also be considered.• Treatment options: Treatment of diabetic ketoacidosis in the pediatric population is performed in a multi-step fashion.The first treatment is usually IV fluids with a 10-20ml/kg fluid bolus.More aggressive hydration initially is contraindicated because there is concern for cerebral edema in pediatric patients who are given too much volume in the setting of DKA.After initial fluid bolus, maintenance fluids can be started at 1.5 x maintenance rate; however, fluids should be monitored closely and altered based on patient's glucose, anion gap, and potassium.In the setting of hypokalemia, potassium supplementation is started with fluid resuscitation, and no insulin is started until the potassium has corrected.If the initial potassium level is normal, insulin and potassium are started, and if the initial potassium is high, fluids alone are started.4

• Past medical history: None • Past surgical history: None • Patient's medications: None • Allergies: None • Social history: No
tobacco, alcohol, or drugs, lives at home with parents, not sexually active •